Bottom Line:
We present the case of a 38 year old lady who was admitted with complaints of worsening breathlessness and low grade fever of one month duration.Examination showed multiple, nontender skin ulcers on bilateral lumbar areas, two oozing serosanguinous discharge and others scarred in the centre.Patient is doing well on antituberculous drugs.

Lupus vulgaris is chronic, postprimary, paucibacillary cutaneous tuberculosis found in individuals with moderate immunity and high degree of tuberculin sensitivity. Eighty percent of the lesions are on the head and neck. We present the case of a 38 year old lady who was admitted with complaints of worsening breathlessness and low grade fever of one month duration. Examination showed multiple, nontender skin ulcers on bilateral lumbar areas, two oozing serosanguinous discharge and others scarred in the centre. Respiratory system examination and chest X-ray revealed right sided pleural effusion. On investigation, pleural fluid was tuberculous in nature. Skin biopsy from the edge of ulcer was also suggestive of tuberculosis. Patient is doing well on antituberculous drugs. This case highlights the importance of cutaneous manifestations of systemic disease and is an example of the unusual presentation of lupus vulgaris in a case of pleural effusion.

Mentions:
Chest X-ray was suggestive of right sided pleural effusion [Figure 2]. Pleural fluid aspiration and analysis was done. Results are detailed in Table 1. Pleural fluid was exudative in nature with 99% lymphocytes and adenosine deaminase level of 108 IU/L, suggestive of tuberculous etiology. Other blood investigation results are given in Table 2. Echocardiography was normal. Intradermal Mantoux (1 TU PPD with RT 23 Tween 80) was positive (12 mm) at the end of 48 hours. Skin biopsy was taken from the edge of the ulcer and histopathological examination was done. It was reported as granulomatous inflammation suggestive of tuberculosis. The biopsy specimen contained multiple granulomas composed of epithelial cells and langhan’s giant cells; areas of necrosis and dense lymphocytic infiltrate [Figure 3]. It did not stain for acid fast bacilli. Diagnosis of pulmonary tuberculosis with lupus vulgaris was made. Patient was started on antituberculous drugs. Pleural effusion and the skin lesions have regressed after eight weeks of antituberculous therapy. Presently she is on rifampicin and isoniazid, continuation phase, for the next four months.

Mentions:
Chest X-ray was suggestive of right sided pleural effusion [Figure 2]. Pleural fluid aspiration and analysis was done. Results are detailed in Table 1. Pleural fluid was exudative in nature with 99% lymphocytes and adenosine deaminase level of 108 IU/L, suggestive of tuberculous etiology. Other blood investigation results are given in Table 2. Echocardiography was normal. Intradermal Mantoux (1 TU PPD with RT 23 Tween 80) was positive (12 mm) at the end of 48 hours. Skin biopsy was taken from the edge of the ulcer and histopathological examination was done. It was reported as granulomatous inflammation suggestive of tuberculosis. The biopsy specimen contained multiple granulomas composed of epithelial cells and langhan’s giant cells; areas of necrosis and dense lymphocytic infiltrate [Figure 3]. It did not stain for acid fast bacilli. Diagnosis of pulmonary tuberculosis with lupus vulgaris was made. Patient was started on antituberculous drugs. Pleural effusion and the skin lesions have regressed after eight weeks of antituberculous therapy. Presently she is on rifampicin and isoniazid, continuation phase, for the next four months.

Bottom Line:
We present the case of a 38 year old lady who was admitted with complaints of worsening breathlessness and low grade fever of one month duration.Examination showed multiple, nontender skin ulcers on bilateral lumbar areas, two oozing serosanguinous discharge and others scarred in the centre.Patient is doing well on antituberculous drugs.

Lupus vulgaris is chronic, postprimary, paucibacillary cutaneous tuberculosis found in individuals with moderate immunity and high degree of tuberculin sensitivity. Eighty percent of the lesions are on the head and neck. We present the case of a 38 year old lady who was admitted with complaints of worsening breathlessness and low grade fever of one month duration. Examination showed multiple, nontender skin ulcers on bilateral lumbar areas, two oozing serosanguinous discharge and others scarred in the centre. Respiratory system examination and chest X-ray revealed right sided pleural effusion. On investigation, pleural fluid was tuberculous in nature. Skin biopsy from the edge of ulcer was also suggestive of tuberculosis. Patient is doing well on antituberculous drugs. This case highlights the importance of cutaneous manifestations of systemic disease and is an example of the unusual presentation of lupus vulgaris in a case of pleural effusion.